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A USEFUL AND QUICK REFERENCE
ABC of Child Abuse, 3rd Edition edited by Roy Meadow, Softcover, 8" x 12".
(A Book from BMJ Publishing Group)
BMJ Books, (An Imprint of the BMJ Publishing Group), BMA House, Tavistock Square, London WC1H 9JR, UK. Publication Date 2000. xii + 85 pages, ISBN 0-7279-1106-6. Price £16.95 (BMA Members £15.95).
This is the third edition of this book, which is part of the BMJ Publishing Group's "ABC" series, and is edited by Sir Roy Meadow. Roy Meadow is a well known British Consultant Paediatrician known for his work in the field of child abuse and in particular in cases of Munchausen Syndrome by proxy. He was a pioneer in the use of covert video surveillance in such cases and has attracted a lot of unwarranted criticism.
The ABC series of books were published as single chapters in the weekly BMJ and are available in book form. The thinking behind the series is to provide a quick reference on the subject mostly for the benefit of non-specialists. Thus the ABC of Child Abuse is recommended for doctors, nurses and other health workers associated with the care of children as well as police officers, members of the legal profession and teachers.
Roy Meadow suggests that "the level of knowledge is that to which a consultant paediatrician should aspire regardless of their particular speciality interest". The level of knowledge is more than sufficient for accident and emergency staff, general practitioners and other medical staff but those who spend a major part of their time in dealing with cases of child abuse are advised to use the references listed as further training. This sums up the scope of the book.
All the chapters have been revised for this edition which is now in its third impression.
The book is the work of thirteen contributors most of whom are paediatricians but there is input from a Forensic Physician (Raine Roberts of Manchester.) There is however no input from a Paediatric Pathologist or a Forensic Pathologist. All except two of the contributors are British. One of the contributors (Sylvia Fraser of Toronto) is an author and journalist and writes about her own experience of being abused by her father. There is also a short contribution by an anonymous writer about her own experience of child abuse.
There are twenty-one chapters (or rather, sections) and the book opens with Epidemiology (see box on right). At the very outset the book emphasises the fact that " A child is considered to be abused if he or she is treated in a way that is unacceptable in a given culture at a given time. This is quite important. This book is likely to find worldwide appeal and its principles applied to cultures where there is likely to be a difference of opinion as to what constitutes child abuse. Furthermore, standards often change with time. Meadow states that "Looking back further there is evidence that the abuse of children by the parents was considered to be culturally acceptable in Britain 100 years ago".
The next chapter (Non-Accidental Injury) discusses diagnostic features, difficulties in diagnosis and investigations. The diagnosis of non-accidental injury in children is an emotionally as well as an intellectually challenging exercise. It is described in the book as one of the most difficult subjects in clinical work, needing time, experience, and emotional energy. The biggest barrier to diagnosis is the existence of emotional blocks in the minds of the professionals. These can be so powerful that they prevent the diagnosis even being considered in quite obvious cases. The diagnosis of non-accidental injury is an important diagnosis and can influence a child's future. It can be a matter of life and death for the child and its siblings. Non-accidental injury is often a marker for emotional abuse and deprivation. Emotional abuse is of course a very difficult diagnosis to make in the absence of physical injury.
The book adds that there are no hard and fast rules and no easy answers for diagnosis of non-accidental injury. Five case reports complete with illustrations are presented in this chapter. This chapter could benefit by the inclusion of more case reports.
The need for additional investigations such as clotting screens is emphasised. The reviewer remembers an occasion when he was nearly caught out when a colleague failed to carry out a clotting screen as instructed.
Chapter three covers Fractures and chapter four Head Injuries. Chris Hobbs, a consultant Paediatrician, has written both chapters. Whilst both chapters are well written both could have benefited from the input of a Radiologist and a Pathologist. The chapter is illustrated with good quality radiographs.
The next two chapters cover Ophthalmic Presentations and Burns and Scalds. Alex Levine who has written the chapter on ophthalmic presentations is an assistant professor of ophthalmology and paediatrics at the University of Toronto. As one would expect the emphasis is on retinal haemorrhages. This section is well written with brief mention of retinal haemorrhages resulting from birth trauma and resuscitation. There is also a section on ocular manifestations of sexually transmitted diseases.
Chapter seven covers Poisoning. A two year survey of non-accidental poisoning in the United Kingdom showed that two thirds of the cases occurred in the context of Munchausen syndrome by proxy and a notorious poison in this context is salt. Most of the other poisons are commonly available remedies (salicylates) or prescription drugs such as phenothiazines. The author of this chapter (Meadow) uses a common sense approach especially to the problem of differentiating accidental poisoning from deliberate poisoning. For example: "Child resistant containers are not childproof..when in doubt about the child's manipulative skills or development it is worth playing with the child to test their ability to open a container or pack of the type described by the parent." Toxicological aspects, collection and preservation of samples are discussed.
The next, rather short chapter discusses Fatal Abuse and Smothering. This chapter which is written by Meadow discusses covert video surveillance and the difficulties involved diagnosing suffocation at autopsy. However, the recent well-publicised correspondence in the BMJ of Suffocation Vs Sudden Infant Death Syndrome is not mentioned.
David Skuse, Professor of Behavioural Sciences at the Hospital For Sick Children, London has written the next two chapters: Emotional Abuse and Neglect and Abuse and Short Stature (the latter with Jane Gilmour, a Research Psychologist). Emotional abuse refers to the habitual verbal harassment of a child by disparagement, criticism, threat and ridicule and the inversion of love; by verbal and non-verbal means rejection and withdrawal are substituted. This is a difficult are for diagnosis and the author warns that: "Current knowledge on the subject does not yet allow us causally to link specific patterns of maltreatment to particular delays and disorders."
There then follows two chapters on child sexual abuse (Child Sexual Abuse-I and II) both written by Raine Roberts with Frank Bamford (a consultant paediatrician). Raine Roberts is a well-known British Forensic Physician who works in the Greater Manchester Police area. The second chapter on child sexual abuse is particularly well illustrated and well written. There is however no mention of the so-called Cleveland Child Abuse Scandal although warnings are made about the limitations of the anal dilatation test.
Meadow has written the next chapter: Munchausen Syndrome by Proxy. Baron von Munchausen (born 1720) was a well-known teller of tall tales! Richard Asher first used the term Munchausen Syndrome in 1951 to patients who travelled widely (from hospital to hospital) and told false stories about their symptoms. The term Munchausen syndrome by proxy was first used in 1977 to describe child abuse caused by mothers who present their children to doctors and hospitals with false stories of illness and by substantiating the stories by fabricating physical signs. There are three different stages of falsification from false-illness-story alone through false-illness-story-plus-fabrication-of-signs to the most serious form: Induced illness.
Dilemmas are discussed in the next chapter also written by Meadow. The diagnosis of child abuse is not a diagnosis to be undertaken lightly. Meadow uses compelling arguments such as "Consideration of abuse as a possible reason for a child's condition and including it in the list of differential diagnoses is a necessary part of everyday practice and does not constitute a false positive diagnosis" to convert the hesitant. He also goes on to lay some myths to rest such as Satanic Abuse and Ritual Abuse. Meadow prefers the term 'organised abuse'. ("Sensational stories are popular with newspapers and have led to extravagant publicity for ritual abuse. Careful investigation usually reveals that the stories are ill founded and much exaggerated")
This is a well-balanced chapter and emphasis is given to false allegations of sexual abuse especially in custody disputes. According to Meadow: In the United States at least one third of the allegations of abuse that are made in the context of custody disputes are false.
There then follows a chapter on the Role of the Child Psychiatry Team and Social Services and Child Protection the latter written by Michael Preston-Shoot, Professor of Social Work and Social Care at Liverpool John Moore's University. He also has written the next chapter on Case Conferences. The Social Services in Britain come in for a fair bit of criticism and case conferences are an essential tool in the communication between agencies.
Barbara Mitchels - a Children's Panel Solicitor, has written the chapter on Child Care Law. She collaborates with Meadow in writing the next two chapters: Medical Reports and About Courts. Doctors in general are very poor witnesses and have difficulty in writing good reports that are acceptable by the courts and easily understood by non-medical persons. These two chapters are therefore very useful. Unfortunately there is no mention of the Scottish legal system. A short paragraph or a table outlining the differences between the legal systems of England (and Wales) and Scotland would have been useful.
The last chapter is Abuse: The Experience written by Sylvia Fraser and an anonymous contributor. Both describe their personal experience of child sexual abuse. In Fraser's case at the hands of her own father and in the second anonymous account at the hands of a stranger. Fraser's contribution consists of extracts from her book: My Father's House-a memoir of incest and of healing published by Virago Press.
The book remains primarily a text for doctors about the recognition and diagnosis of child abuse. It is of a large format measuring 30 x 21 cms (A4 sized) and runs to 85 pages. Apart from a few of the chapters the book is lavishly illustrated with colour photographs of a very good quality and black and white radiographs. There are also a number of clearly drawn line drawings and charts. The reproduction is excellent and the book is printed on coated paper. Each chapter has a list of suggested publications for further reading and there is a standard index.
The book is full of instructive quotes. Sample some of them:
The ABC series never pretends to be comprehensive texts. Neither are they 'idiot's guides'! Being a Forensic Pathologist and having worked as a Police Surgeon (Forensic Physician) in the past, there was nothing new in this book for me but I would recommend it to Police Child Protection Officers and trainee forensic pathologists (in addition those that the book has already been recommended to.)
Dr. Gyan Fernando has worked as a Police Surgeon (Forensic Medical Examiner) in Scotland mostly for the Tayside Police and the Lothian and Borders Police. This was in addition to his duties as a forensic pathologist and Senior Lecturer in Forensic Medicine for the University of Dundee and later the University of Edinburgh. He is now the Home Office Pathologist for Devon and Cornwall.
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